10. Have you ever had any disciplinary action taken or charges filed against your dental license or other
health related license by a government agency?
“License” includes permits, registrations, and certificates. Include any disciplinary actions taken by
this agency, any other state agency, any U.S. territory, the U.S. Military, U.S. Public Health Service
or other U.S. federal governmental entity. Disciplinary action includes, but is not limited to,
suspension, revocation, probation, confidential discipline, consent order, letter of reprimand or
warning, or any other restriction or action taken against a dental or health-related license that
was issued to you.
If the answer is “yes”, provide the section of law violated the nature of the violation, the location
and date of the violation, and the penalty or disposition on a separate sheet and include with this
11. Have you ever had a dental or other health-related license denied in this state or any other state?
If “yes”, provide a detailed explanation of circumstances surrounding the denial, including the
date of the denial, type of application, and the basis for the denial. Include a copy of any
document(s) you received from the agency denying your application(s).
12. Have you ever surrendered a dental license, either voluntarily or otherwise?
If “yes”, provide a detailed explanation of the circumstances, including the date of the surrender,
the reason for the surrender and a copy of all documents relating to the surrender.
13. EVIDENCE OF COMPLETION OF REQUIRED CERTIFICATIONS
Candidates for the RDA examination must submit evidence of having completed the following Board-
(check all requirements completed) Evidence of completion shall be attached to the
Radiation Safety Coronal Polishing Infection Control CA Dental Practice Basic Life Support Live Scan
(32-hour course) (16-hour course) (8-hour course) Act (2hour course) (AHA/ARC) Form
14. EXECUTION OF APPLICATION
I am the applicant for examination for licensure referred to above. I have read the questions in the foregoing
application and have answered them truthfully, fully and completely.
I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Signed in on t he of , 20_____.
(City/State) (Day) (Month) (Yr)
(Signature of Applicant)